Seguimiento de los pacientes con lupus eritematoso sistémico: lo que no está en las guías / Follow-up of patients with systemic lupus erythematosus: what is not found in the guidelines

Se comentan una serie de medidas para los pacientes con lupus eritematoso sistémico, que no suelen estar en las guías. Al enfermo muy bien controlado durante años tendemos a ir reduciendo progresivamente la dosis de hidroxicloroquina, sin bajar de aproximadamente 600mg/semana. Este fármaco aconsejamos tomarlo por la mañana en los pacientes con insomnio, por la noche en los casos de dispepsia y en los que presentan prurito de tipo acuagénico que separen la toma de la ducha, y que esta sea con agua lo menos caliente posible. No usamos el tratamiento con prednisona a días alternos, y excepcionalmente dividimos la dosis en ¾ antes del desayuno y ¼ antes de la cena. En consultas deberíamos dedicar entre 20 y 30min por paciente, para hacer una buena práctica clínica y humana. En nuestra unidad hemos analizado el seguimiento de 112 enfermos consecutivos, y el 71,4% tenían una sintomatología no explicable por el lupus, y solamente al 8,9% los derivamos a otros especialistas, probablemente, por nuestra capacitación general como internistas. Sugerimos que conocer la opinión de los especialistas dedicados a tratar a los enfermos con lupus puede ser de interés, pues a partir de sus experiencias, se pueden programar trabajos bien diseñados, que permitirían el avance en el conocimiento de esta enfermedad (AU)

A series of measures in the management of patients with systemic lupus erythematosus (SLE) which usually are not found in the lupus guidelines are discussed. In the lupus patient who has been well-controlled in the long term, the dose of hydroxychloroquine should be progressively reduced, without decreasing more than approximately 600mg per week. We recommend taking this drug in the morning in patients with insomnia, at night in those with dyspepsia and to separate the intake of the drug from the shower (and the water should be as cool as possible) in those patients with aquagenic pruritus. We do not use prednisone on alternate days and exceptionally divide the dose into ¾ before breakfast and ¼ before dinner. Twenty to 30min should be used per patient in every scheduled visit to assure a good clinical and human practice. We analyzed the follow-up of 112 consecutive patients from our systemic disease unit and found that 71.4% of them had symptoms that were unexplained by lupus and we only referred 8.9% of them to other specialists, probably because of our general training as internal medicine doctors. We suggest that knowing the views of SLE specialists might be of interest since, well-designed studies that would allow to progress in the understanding of this disease could be performed based on their experience (AU)

Follow-up of patients with systemic lupus erythematosus: what is not found in the guidelines.

A series of measures in the management of patients with systemic lupus erythematosus (SLE) which usually are not found in the lupus guidelines are discussed. In the lupus patient who has been well-controlled in the long term, the dose of hydroxychloroquine should be progressively reduced, without decreasing more than approximately 600 mg per week. We recommend taking this drug in the morning in patients with insomnia, at night in those with dyspepsia and to separate the intake of the drug from the shower (and the water should be as cool as possible) in those patients with aquagenic pruritus. We do not use prednisone on alternate days and exceptionally divide the dose into ¾ before breakfast and » before dinner. Twenty to 30 min should be used per patient in every scheduled visit to assure a good clinical and human practice. We analyzed the follow-up of 112 consecutive patients from our systemic disease unit and found that 71.4% of them had symptoms that were unexplained by lupus and we only referred 8.9% of them to other specialists, probably because of our general training as internal medicine doctors. We suggest that knowing the views of SLE specialists might be of interest since, well-designed studies that would allow to progress in the understanding of this disease could be performed based on their experience.

Correlation of asymptomatic hyperuricaemia and serum uric acid levels with arterial stiffness in women with systemic lupus erythematosus without clinically evident atherosclerotic cardiovascular disease.

The objective of this article was to evaluate whether serum uric acid (SUA) correlates with arterial stiffness and inflammation markers in a cohort of women with systemic lupus erythematosus (SLE) without overt atherosclerotic cardiovascular diseases, who attended a community hospital. One hundred and two women with SLE were assessed as part of this cross-sectional study. Carotid-femoral pulse wave velocity (PWV) was measured using an automatic device (Complior). C-reactive protein (CRP), fibrinogen and homocysteine levels as well as other metabolic results were recorded. Duration and activity of SLE, damage accrual and treatments were recorded. SLE women were categorized as having or not having hyperuricaemia (HU) according to SUA levels (greater than or up to 6.2 mg/dl, respectively). A multiple linear regression analysis was used to determine the independent link between SUA levels and other variables. Women with SLE and HU (n = 15, 15%) had a worse cardiovascular risk profile that included ageing, hypertension, obesity, higher total cholesterol levels, renal failure and presence of metabolic syndrome. Also, the duration of SLE was increased and damage accrual was greater. In the unadjusted analysis, SUA levels correlated with PWV, CRP, fibrinogen and homocysteine. However, in a multivariate linear regression analysis, SUA levels independently correlated with the duration of SLE, creatinine, total cholesterol and homocysteine levels but did not correlate with PWV. In conclusion, SUA was associated with arterial stiffness, but not independently of age and homocysteine levels. Nevertheless, SUA might be an ancillary indicator of subclinical atherosclerosis in SLE women without clinically evident atherosclerotic cardiovascular disease.

In-vitro radiosensitivity in patients with systemic lupus erythematosus.

To determine the "in-vitro" intrinsic cell radiosensitivity (RS) as a risk indicator of radiation-related side-effects in patients with systemic lupus erythematosus (SLE) compared with healthy subjects (control group). Moreover, we elucidated if clinical, therapeutic and biological parameters could affect the "in-vitro" intrinsic RS in patients with SLE. Intrinsic RS was determined by the quantification of the initial radiation-induced DNA double-strand breaks in peripheral lymphocytes, measured by pulsed-field gel electrophoresis from 52 patients with SLE and a control group consisting of 48 sex- and age-matched healthy subjects. No difference in intrinsic RS was found among both groups. However, SLE patients with anaemia, increased erythrocyte sedimentation rate and those with positive result for anti-La/SSB and anti-RNP antibodies showed significantly higher DNA double-strand breaks than those without them. In our study, patients with SLE did not have a higher intrinsic RS than healthy subjects. According to these results, and with the caution of being a limited laboratory study, the use of radiotherapy should not be avoided in patients with SLE when it is clinically needed.

[Intolerance to hydroxychloroquine marketed in Spain (Dolquine) in patients with autoimmune conditions]. / Intolerancia a la hidroxicloroquina comercializada en España (Dolquine) en pacientes con patología autoinmune.

BASIS: A significant proportion of our patients has described to have problems from tolerance to Dolquine, a new presentation of hydroxychloroquine recently marketed in Spain, compared to Plaquenil. The objective was to know the tolerability and the adverse effects of this new presentation. PATIENTS AND METHOD: A cross-sectional multicenter study on 133 patients treated with Dolquine was conducted. RESULTS: Of the 133 patients (87% women; average age [AA]: 32.9 [15.4] years) who received Dolquine during an average period of 6.7 (1.4) months, 32 patients (24%) described to have more problems with this drug in comparison with other antimalarial. The adverse effects experienced were: bitter taste (62.4%), difficulty in swallowing the tablet (13.5%), dyspepsia (9.8%), nausea (7.5%), vomiting (1.5%), pruritus (1.5%), diarrhea (0.7%), and instability feeling (0.7%). The presence of gastrointestinal adverse effects was not related to the consumption of gastroerosive drugs, gastric protectors, or a high number of drugs. The attrition rate was 9.8%. Conclusions. Dolquine induces lower tolerance and more gastrointestinal adverse effects than Plaquenil, pointing out its bitter taste and the difficulty in swallowing it. Despite this higher intolerance there was not an increase in the attition rate from the antimalarial treatment in comparison to other series.

Systemic lupus erythematosus in southern Spain: a comparative clinical and genetic study between Caucasian and Gypsy patients.

We evaluated the influence of the hereditary make-up on the development of systemic lupus erythematosus (SLE) in two ethnic groups [Gypsy and white Caucasian Mediterranean (WCM) populations], living in the same geographic area. We compared 81 WCM and 25 Gypsy patients with SLE. The control group consisted of 185 healthy unrelated individuals, 105 WC and 80 Gypsies. In the Gypsy population, the onset of SLE occurred at earlier ages than in the other ethnic group (25.9 versus 32.0 years, P = 0.02), and showed lower SLEDAI peak values (4.9 versus 7.0, P = 0.016). The frequency of joint, kidney, gastrointestinal and eye involvement was significantly lower in Gypsy patients. In contrast, SLE-associated antiphospholipid syndrome, thrombosis and livedo reticularis were more frequent in Gypsies than in the majority ethnic group (WCM). In WCM patients, DRB1* 1303-DQB1*0301 haplotype was associated with SLE (P = 0.001, Pc = 0.038). We found SLE to be associated with DR5 (P = 0.006, Pc = 0.05) in the Gypsy population as well as a protective effect of DPB1*0401 when DR5 was not present (P = 0.008, Pc = 0.032). In conclusion, we found some clinical differences between WCM and Gypsy patients with SLE. Furthermore, HLA associations between HLA-DRB1-DQB1 and SLE were different for Gypsy people.

Hair dye treatment use and clinical course in patients with systemic lupus erythematosus and cutaneous lupus.

The etiological role of hair dye treatment (HDT), some of them such as permanent hair dyes containing aromatic amines, in the development of SLE has been previously ruled out. However, the possible influence of HDT use on the course and prognosis of lupus patients has been assessed only in one short-term study. Since HDT is very extensive among the population, the knowledge of this possible negative effect may be very important. Thus, the aim of this study was to assess the long-term influence of several HDTs on the course and clinical severity of patients with both systemic lupus erythematosus (SLE) and cutaneous lupus (CL). In this longitudinal case series study, 91 SLE patients and 22 CL patients were prospectively studied from October 1988 to May 2000. They were divided into three groups: (a) non-HDT users--patients who have never used HDT (n = 65); (b) P-HDT users--HDT permanent type users, alone or in combination with other types of HDT (n = 28); (c) non P-HDT--users of other treatments different from permanent tinting (bleach, lowlights, etc; n = 20). In each patient we determined: (1) number of flares/year in SLE patients and worsening of cutaneous lesions for CL; (2) Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage index; (3) predominant damaged organs/systems according to the HDT use and type of HDT; and (4) subjective impression about the disease evolution in relation to HDT use. No significant differences were found with respect to flares/year and SLICC/ACR damage index between the study groups. Non-HDT group presented more renal involvement and serositis than both HDT-user groups. No patient related the HDT use to the worsening of his disease. Therefore, in this study no evidence of an association between the long-term use of several types of HDT and the clinical activity and course of SLE and CL was found.

Activity of the gamma-glutamyltransferase, leucine aminopeptidase and alkaline phosphatase enzymes in human tear fluid.

In this work the presence of gamma-glutamyltransferase (GGT), leucine amino-peptidase (LAP) and alkaline phosphatase (AP) is shown in human tear fluid. We studied these levels according to sex, age and some eye refraction defects. The differences between the levels for both sexes are not significant. LAP and AP do not show any differences in either age groups or individuals with some refraction defects. The average level of GGT is higher from 40 years of age upwards (p less than 0.005). In individuals with refraction defects, the enzymatic activity is significantly higher (p less than 0.05) than the activities found in normal subjects. The levels of the three enzymes in serum and tear fluid do not show a significant correlation nor are they significantly modified after the samples have been frozen for a month at -20 degrees C.

Salivary gamma-glutamyl transferase activity in internal diseases.

Salivary gamma-glutamyl transferase (GGT) activity was measured in 116 patients with several diseases that involved the hepatobiliary tract, pancreas, and miscellaneous disorders and in 20 normal subjects. We have found significantly elevated values of salivary GGT in cirrhosis of the liver (8.3 +/- 0.9 [mean +/- SEM] units/L), hepatic tumors (10.4 +/- 1.3 units/L), acute cholecystitis (18.3 +/- 2 units/L), acute pancreatitis (15.1 +/- 2.4 units/L), diabetic ketoacidosis (11.6 +/- 1 units/L), and Sjögren's syndrome (19.6 +/- 4.8 units/L). Salivary GGT activities were unmodified in fatty liver, infectious hepatitis, silent cholelithiasis, and mumps. Several mechanisms explain high salivary GGT activity. Measurement of salivary GGT activity in internal medicine merits further investigations to determine its potential diagnostic value.

[Gamma-glutamyltransferase and alkaline phosphatase in the serum and saliva of patients with hepatic tumors and hepatic cirrhosis]. / Gamma-glutamil transferasa y fosfatasa alcalina en suero y saliva de enfermos con tumores hepáticos y cirrosis hepática.

The authors have previously described the presence of gammaglutamyl transferase and alkaline phosphatase in the saliva of healthy individuals and of patients with hepatobiliary and pancreatic diseases. The authors show in this work the values of said enzymes in the blood serum and saliva of 23 cases of liver cirrhosis and 17 patients with liver tumors. Both enzymes increase significantly in the serum of liver tumor patients with respect to the amounts found in liver cirrhosis patients (p less than 0.005). Alkaline phosphatase increased significantly in the saliva of patients with liver cirrhosis (p less than 0.005), where as no differences were found between the two groups of patients with liver cirrhosis (p less than 0.005), where as no differences were found between the two groups of patients for the salivary gamma-glutamyl transferase. The determination of seric alkaline phosphatase and gamma-glutamyl transferase, and of salivary alkaline phosphatase may be useful for the differential diagnosis between liver cirrhosis and liver tumor.